Second Opinion Benefits. Health plans, payers, employer groups. Medical Review Institute of America MRIoA. 2nd

Why Health Plans and Employer Groups Should Embrace Obtaining a Second Opinion

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There are many reasons why an individual may want to obtain a second opinion on a diagnosis made or to confirm a particular medical procedure suggested or ordered by a physician. Likewise, there are many reasons why health plans and employer groups may want to support their members and employees in obtaining a second medical opinion. Regardless of the reasons, the overarching goal for obtaining a second medical opinion should be assisting health plan members and company employees with obtaining the best possible medical outcome at the lowest overall cost in the most expeditious, hassle-free manner possible.

Reasons to Support a Second Opinion as a Member Benefit

The following are key reasons why health plans and employer groups should support their members and employees with obtaining a second opinion.

  • Increases the quality of care and lowers costs associated with overutilization by incorporating an objective clinical review using evidence-based medicine.
  • Provides additional informed choices from other medical experts.
  • May incorporate specialized data and technologies that can provide a better clinical outcome.
  • Provides the individual with a more personalized approach to care.
  • Serves as a complimentary benefit to the individual that empowers the individual to make decisions in their own personal “best interest.”
  • Serves as an objective review void of any personal incentive to the reviewing physician beyond providing the best medical advice possible.
  • Increases the speed and accuracy of prior authorization requests via a digital, evidence-based healthcare platform.
  • Potential cost savings for the patient, plan, and providers via comprehensive member education, virtual consults, and alternative, conservative therapy options, and other treatment choices.
  • May alleviate physician shortages so that specialists are providing care to those that really need care – not overtreating or providing costly but low-value care.

Key Considerations for Selecting a Second Opinion Provider

Health plans and employer groups considering the use of an organization providing second opinions should consider the following:

Support Services Across Wide Range of Medical and Surgical Specialties

Organizations providing second opinion services should have a large network of physicians and health reviewers able to provide coverage across key specialties – not just the Big Four (cancer, heart disease, diabetes, and lung disease).

Offer Patient Education and Suggest Alternative Treatment Options

Where applicable, second opinion providers should offer patient education about their condition and alternative, conservative therapy options and other treatment choices.

Ability to Scale, Securely Process, and Store Health Information

Second opinion providers must be able to scale their service volumes using a digital platform capable of effective stakeholder interaction and efficiently processing large volumes of medical data in a secure, HIPAA-compliant environment.

Provide a Rapid Turnaround Time

A rapid turnaround from the time all medical documentation is received to the time the second opinion is provided is critical – particularly in regard to plan member, employee, and patient experience.

Return on Investment Including Improved Member Satisfaction Ratings

Second opinion providers should provide benchmarking analytics and information substantiating the return on investment of their second opinion program. Additionally, the organization should be able to assist with providing data to support quality measures like Star Ratings.

Learning More About the Value of Supporting Second Opinions

To learn more about the value of supporting second opinions for health plan members and employees, join us on Thursday, October 14, 2021, at 11:00 AM PT / 2:00 PM ET for an HCEG Webinar Series Event: Using Virtual 2nd Opinions to Increase Member Engagement and Decrease Healthcare Costs.

In this webinar presented by Medical Review Institute of America (MRIoA), you’ll learn additional details on supporting second opinions for plan members and employees and other considerations including the following:

  • How using second opinions can optimize medications and positively impact member health at lower overall cost
  • Understanding the risks and recovery implications with respect to the initial diagnosis and alternative treatments
  • How health plans and self-insured employers can save money by offering virtual second opinions for high-cost/high-risk proceduresSecond Opinion Benefits. Health plans, payers, employer groups. Medical Review Institute of America MRIoA. 2nd
Health Plans Intelligent Care Management Technologies. EHR Integration. Value-based payment programs. HELIOS. Closing the Loop.

5 Reasons Why Health Plans Must Adopt Intelligent Care Management Technologies

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Over the last 10+ years, nearly all health systems and healthcare providers have adopted some sort of electronic health record system (EHR). And since the start of the pandemic, these care providers have accelerated the use of telemedicine and remote patient monitoring tools to support their care management services. In addition, healthcare consumers are increasing their use of apps to manage their health, well-being, and related spending. These technology-based developments have enabled the collection of patient, clinical, and financial data in types and volumes never before possible; data that is essential to the operation of value-based payment programs.

Health Plans as ‘Keepers of the Data’ Need Advanced Care Management Capabilities

Moreover, recent regulations on data transparency, interoperability, and patients’ access to their data are strengthening health plans as a central repository of longitudinal aggregated data for plan members. By leveraging that data with technologies like artificial intelligence, machine learning, and robotic process automation, health plans are able to assist their provider networks with identifying, delivering, and closing the loop on the preventative, ‘whole-person’ and other population health management services critical to value-based programs.

RELATED:Intelligent Care Management Technology: Driving Alignment Towards The Quadruple Aim – Webinar, Thursday, October 7th, 2021 at 3:00 PM ET

Intelligent Care Management – Exceeding Typical Health Plan Capabilities

Intelligent Care Management Technologies (ICMT) go beyond the often disjointed utilization management, case management, and other clinically-focused services historically performed by health plans and provides an integrated, holistic approach to care.

Here are five reasons why health plans should be adopting Intelligent Care Management Technologies:

  1. Improves Patient Outcomes by Facilitating a Whole-Person Approach to Care

Being able to integrate, interpret, and efficiently utilize large data sets that span an individual’s entire health profile allows plans to help their provider network deliver insight and care at the right time and place. Potential life-threatening issues and medical complications can be caught sooner, enabling care providers to improve patient outcomes with fewer resources and at a lower cost.

  1. Extends Value of Provider Systems and Resources

Beyond not having a more complete patient profile, many care providers lack advanced analytics, guidelines, and tools that plans are better equipped to provide. The intelligent care management technologies shared by a health plan can positively impact provider practice patterns and improve overall care delivery to their patients and the plan’s members.

  1. Reduces Burden and Expense of Provider Network Partners

ICMT is integrated with existing provider and plan workflows with context, priority, and transparency to support faster and more informed care decisions by network physicians, nurses, and other care provider resources. Supporting clinicians helps to reduce the burden of increasing patient volumes and contributes to achieving the Quadruple Aim.

  1. Helps Address Social Determinants of Health and Leverages Community-Based ResourcesHealth Plans Intelligent Care Management Technologies. EHR Integration. Value-based payment programs. HELIOS. Closing the Loop.

ICMT helps tailor care based on social determinants of health, assessment tools, and guidelines to help identify, coordinate, and close the loop on services provided by network providers and local community-based organizations. Closing care gaps and assisting members and patients with obtaining medical and non-medical services from local organizations is an important part of value-based payment programs.

  1. Enables Health Plans to Assist Network Providers with Taking on More Risk

As care provider organizations and payers enter into more value-based care arrangements, it is critical for those organizations to strategically take on more risk and equitably share the cost of providing that care. Money spent on reactive care, avoidable hospital readmissions, and services performed in costly settings – among other things – are not only a waste of money but also burden increasingly scarce provider resources and negatively impact the patient experience. Intelligent Care Management Technologies allow plans to support their provider network by identifying, helping to coordinate and close the loop on proactive care across the care continuum.

RELATED: Intelligent Care Management Technologies: Key Considerations & Opportunities

Spreading Intelligence to Traditional Care Management

As the transition from fee-for-service to value-based payment programs accelerates and employers and consumers demand more their healthcare dollars, payers and providers must work with each other in more collaborative, intertwined ways. Utilizing intelligent care management technologies enables and supports the payer-provider collaboration essential to operating in today’s healthcare environment; and value-based arrangements in particular.

To learn more from healthcare leaders intimately involved with implementing and operating intelligent care management technologies, join us on Thursday, October 7th, 2021 at 3:00 PM ET for our live webinar “Intelligent Care Management Technology: Driving Alignment Towards The Quadruple Aim” presented by VirtualHealth.Health Plans Intelligent Care Management Technologies. EHR Integration. Value-based payment programs. HELIOSIf you’re not available, register anyway and we’ll send you a recording including presentation materials after the event.

ocus Area Roundtable on Next-Generation Value-Based Payment Programs

Value-Based Payment Programs – Highlights from Recent Roundtable

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Like other systemic changes needed to ‘fix healthcare’ in the United States that have been proposed, discussed, and tried in various forms and fashions over the last 20 years, the widespread, meaningful adoption of value-based payment programs seems to always be just a few years away. And now, the coronavirus pandemic has forced all healthcare stakeholders to re-think what is needed to truly transform the healthcare delivery system in the United States. In our first Focus Area Roundtable on Next-Generation Value-Based Payment Programs, participants discussed obstacles to value-based payment programs, selecting and measuring quality measures and outcomes, and topics related to engaging stakeholders – particularly payers and providers – collaboratively and in a proactive vs. reactive manner.

HCEG’s Executive Director Ferris Taylor and Eileen Lee, VP of Product – Connected Solutions, at Zelis Healthcare, helped facilitate discussion among roundtable participants: leaders from health plans, health systems, care provider organizations, and two consultants serving the healthcare industry. This post presents highlights of the roundtable. Individuals involved with transforming their provider reimbursement and payment systems are welcome to join our Focus Area Roundtables including the 2nd roundtable on Next-Generation Value-Based Payment Programs.

Next-Generation Value-Based Payment Programs. Quality measures and outcomes. preventative health. Smaller, regional, commercial health plans. Fee-for-service payments (FFS). FHIR. EHR. CDS Hooks.Obstacles to Wider Adoption of Value-Based Payment Programs

Ferris kicked off the roundtable by asking participants to share their thoughts on what obstacles are hampering the increased adoption of value-based care and payment programs.

Eileen Lee shared her perspective that many smaller, regional, commercial health plans simply don’t have the infrastructure or the resources to change the framework for how they process payments. She noted that with current infrastructures built around making fee-for-service payments (FFS) and high costs associated with implementing and administrating both FFS and value-based payment programs, the opportunity for these types of organizations to evolve is simply not available to them.

Expanding Provider Networks and Accessing Data in EHR’s

Obstacles to Value-Based Payment

A chief technology officer of a health plan stated that their commercial plans still operate predominantly in a fee-for-service model and that they face two challenges in expanding their value-based payment footprint: developing their value-based provider networks and getting hospitals to participate and being able to connect into provider EHR systems to be able to send messages back and forth to support inpatient wellness and preventative health activities.

Eileen questioned whether engaging providers to participate in value-based programs was related to providers being unwilling to accept risk or whether they didn’t want the additional burden associated with collecting and reporting data.

One participant working with the front-line of care delivery shared that a big challenge for the front-line – from a value-based program’s perspective – is that collecting program metrics is ‘just another thing to do.’ She noted that if new data collection requirements can be better integrated into daily activities and workflow, value-based programs would be better accepted – particularly by physicians.

RELATED: Will Administrative Cost of Independent Dispute Resolution Force Providers to Join Networks?

Dealing with Different Requirements from Multiple Payers

In response to this comment on fitting into clinician workflow, Eileen reminded the roundtable that each payer has its own requirements and processes that clinicians must adhere to. The roundtable acknowledged the importance of recognizing and addressing payer-specific requirements, using standards and common definitions to the greatest extent possible, and selecting easily adaptable processes across multiple payers.

Capturing Meaningful Metrics as Part of Doing Business as Usual

One participant shared that, from his perspective, some Accountable Care Organization’s (ACO) are so concentrated on maximizing revenue by focusing on meeting quality measures and reporting end of year metrics, that innovations in care are not really welcomed. He noted that many metrics used for value-based programs should be captured and reported as a normal course of providing patient services – not just because they are required to receive specific payment program incentives.

The ability to incorporate data like laboratory values, medication lists, patient surveys, and other data that does not rely on inputs from clinicians or payers to support new payment models is one consideration noted in roundtable discussion.

Total Cost of Care Essential to Execute Value-Based Payment Programs

One participant associated with providing post-acute care in the home noted that the ability to accurately measure the total cost of care is key to being able to execute its value-based payment programs. She claimed that they don’t have access to all the data needed to be able to calculate the total cost of care.

Eileen asked if she thought that some of the transparency and coverage rule mandates will make calculating the total cost of care easier. The participant noted that they may if they were able to get eligibility data feeds to understand benefit coverage but obtaining that data is still up to the health plans to decide whether or not to share that data.

Measuring Quality, Outcomes, and Cost for Value-Based Payment Programs

Ferris asked the roundtable to share their thoughts on measuring quality, outcomes, and cost for value-based payment programs.Next-Generation Value-Based Payment Programs. Quality measures. Cost of Care. Outcomes.

One participant noted their plan’s success with a value-based contract on heart failure using pharmaceuticals. He explained that what makes that agreement work is that it can be measured. They know when people take their medication whether it works for them or does not work for them based on claims data and information easily reported by the physician. And they have a very measurable outcome. He went on to say that costs savings can be measured using claims data.

Another participant, a manager of clinical integration at a regional, integrated healthcare provider/payer system, asked participants if it was possible for value-based care program outcomes to be measured with claims volume alone. And could a program be deemed ‘better’ due to the ability to measure its outcomes based on claims data alone without other patient artifacts in order to determine the quality of outcomes?

A health plan CIO stated that claims data alone is not enough in almost all cases and that clinical data is needed as well. Another person added that benchmarks are also needed to know how you’re performing relative to some baseline.

How the Pandemic has Impacted Value-Based Payment Programs

Eileen from Zelis questioned the group on how the pandemic has impacted value-based care. She noted that at the beginning of the pandemic, providers that were participating in value-based care and payment plans had a little bit less of an impact from the drop in service volumes. But now that patients have spent a year delaying care, Eileen wonders if providers are or will be seeing more negative outcomes even while they (physicians) are still providing the same historical level of care.

Providers Anticipating Increased Risk Due to Pandemic-Induced Delays to Care

Eileen went on to share observations on two trends emerging since the pandemic started in Q1 of 2020. She stated that there has been an increase in interest among providers in value-based care and value-based payments as a way to ward off the negative impacts of fee-for-service when patients stopped coming; noting providers see value-based payment programs as a leveling – a way to help manage their risk and keep their cash flow moving.

She added that she expects data to reveal the same trend about preventive care and about the severity of illness coming into ER’s that others are seeing. And wonders what that may mean for long-term outcomes and the measurement of those outcomes for purposes of value-based care payment. Eileen noted that it may be more difficult for physicians to get incentive payments and show high-quality metrics if their patients simply don’t participate in the care gap closing activities that they need to participate in order for there to be quality care outcomes. Listen here for pandemic’s impact on adoption of value-based payment programs [00:38:34 – 00:40:01]

Managing Patient Migration Outside the Network – Incentivizing Collaboration

One participant shared that supporting the ability of their network physicians to collaborate and communicate with other network physicians – and incentivizing them to do so – has had a large positive effect on both total cost of care point and outcomes relative to patient’s risk profile and chronic conditions: fewer ED visits and readmissions to inpatient care.

In line with comments made by Eileen Lee about the decrease in preventative services since the pandemic began, this participant noted that managing this so-called ‘migration outside the network’ has been hampered by the decrease in preventive care services utilized by many plan members and patients since the start of the pandemic in Q1 of 2020.

Other Considerations on Capturing Metrics and Improving Outcomes under Value-based Payment Programs

Participants shared insights and observations on other ways to capture metrics and improve outcomes under value-based payment programs – particularly as more and more services are moving from traditional acute care settings to community and home-based settings:

Delivering Care in the Home and Use of Remote Monitoring Technologies

One person noted seeing opportunities created for digital startups, especially remote patient monitoring startups where organizations can outsource some of the patient monitoring part and then receive great insights from these new companies only when it is needed. Listen here for more on new opportunities for supporting value-based payment programs [00:31:25 – 00:32:56]Delivering Care in the Home and Use of Remote Monitoring Technologies Challenge in Accessing and Capturing Outcomes Data in the Home – Alleviated by OASIS Data

Challenge in Accessing and Capturing Outcomes Data in the Home – Alleviated by OASIS Data?

Building on the idea of diagnosing, monitoring, and providing care in the home, Ferris asked one participant, a provider of post-acute services in the home, how they are capturing measures and outcomes data in the home care environment and whether that data is captured in an EHR.

The participant shared that, ideally, the delivery of home-based services would be integrated with EHRs but to do that they must obtain provider by provider approval to get access to providers’ EMR’s. She shared that another way they are looking at getting data is to try to get access to the Outcome and Assessment Information Set (OASIS) data because that is standard across all home health providers. She noted that using the OASIS data requires a technology solution to receive the data, integrate it into their technical architecture, and be able to manipulate and trend the data.

Impact of FHIR-Based Use Cases on Value-Based Payment Programs

Next-Generation Value-Based Payment Programs. Quality measures. Cost of Care. Outcomes. Technologies. FHIR. CDS Hooks. MessagingOne participant asked whether use cases based on the FHIR – the foundational standard to support data exchange via secure application programming interfaces (API) – would have a positive impact on value-based care programs. The CTO mentioned previously noted that integration of Smart on FHIR-based apps running on a provider’s EHR would be a positive step toward obtaining data needed for value-based payment programs.

He also mentioned the use of new standard messaging and data exchange tools between payers and providers that utilize ‘CDS Hooks.’  Unfortunately, while the standards exist, leveraging them is still a one-on-one approach necessitating working with a FHIR vendor and integrating the back-and-forth integration.

While Ferris noted CMS’s Interoperability and Patient Access Final Rule now in effect as an example of a positive data exchange development between healthcare stakeholders, Eileen clarified that 67% of Americans are covered by self-funded or TPA plans that are not subject to the rule.

RELATED: Balancing Amount of Data Shared with Providers – Increasing Impact of Value-based Arrangements

Closing Thoughts on Next-Generation Value-Based Payment Programs

Ferris asked Eileen Lee of Zelis to wrap up the roundtable by offering a closing comment. Eileen shared that the adoption of value-based payment programs is one of those scenarios where the problem is easy to see and the solution seems even easier to decide but implementing it is complicated due to the diverse and diffuse environment of healthcare in the United States.

Listen here to Eileen Lee comment on the movement to Next-Generation Value-based Payment Programs [00:44:40 – 00:45:40]

Share Insight & Opinion on Value-Based Payment Programs and Join Our Next Roundtable

To assess payment-related challenges payers and providers are experiencing, identify gaps in the current payer-provider payment system, and help determine what’s holding back the adoption of new payer-provider payment solutions, the HealthCare Executive Group has created a mini-survey on Payer-Provider Payment Solutions. Healthcare stakeholders are urged to complete this three-minute survey. All survey respondents can receive survey results and be entered into a drawing for one of four $25 Amazon gift cards.HCEG Focus Area Roundtable. HealthCare Executive Group. Next-Generation Value-Based Payment Programs. Zelis Healthcare. Quality measures and outcomes.

Join our next roundtable on Next-Generation Value-Based Payment Programs on Tuesday, October 26, 2021, at 2:00 PM ET where additional insight, real-world experiences, and the latest developments on value-based payment programs will be discussed.

Join 7600+ other healthcare leaders and changemakers by subscribing to our newsletter and connecting with us on Twitter and LinkedIn.

Payment Integrity. Fair and Equitable, Structurally Sound Payment System. Healthcare. payment reform. provider payment models. Value-based care.

Payment Integrity’s Role in Building a Fair & Equitable, Structurally Sound Payment System

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Each year over the last decade, ‘Healthcare Payment’ and ‘Data & Analytics’ have been on the HCEG Top 10 list of challenges, issues, and opportunities facing healthcare leaders; whether payment reform, big data and advanced analytics, payment integrity, or as in the case of the most current 2021 HCEG Top 10+ list: ‘Data & Analytics with respect to Costs.’ And now, the pandemic’s impact on healthcare provider revenue, the increasing financial responsibility of individuals for high and widely priced healthcare services, and multiple price transparency regulations such as the No Surprises Act and Transparency in Coverage are forcing stakeholders across the industry to address fundamental structural issues surrounding healthcare payments and provider reimbursement.

On Thursday, September 9th, the first in a series of Focus Area Roundtables on Payment Integrity and ‘Data & Analytics with respect to Costs’ took place with HCEG’s executive director Ferris Taylor joined by Kurt Fullmer and Andrew Cone, two healthcare industry leaders with MultiPlan – HCEG’s Focus Area Partner for ‘Data & Analytics with respect to Costs’. Seventeen other leaders from health plans, health systems, provider organizations including IPA’s, and industry consultants joined the roundtable discussion focused on the following topics:

1-How providers and payors – and plan members and patients – can find common ground in terms of payment and reimbursement
2-The ways the No Surprises Act may change the future of provider networks and reimbursement
3-How payment integrity must evolve to be considered by providers as fair and equitable

RELATED: Trends that are re-shaping payment integrity strategies

Finding Common Ground Among Payers, Providers, Plan Members, & Patients

Ferris kicked off the roundtable by asking how healthcare stakeholders could find common ground in terms of reimbursement. MultiPlan’s Andrew Cone noted the importance of keeping in mind the wide degree of variance that exists in the healthcare market across product types such as Medicare, Medicaid, Commercial, Group, Individual, etc. There’s a clear benefit to payers and providers to adopt consistent patient attribution approaches, quality measurement, and risk adjustment practices across all product types.

He also called out the way in which healthcare services are priced relative to other major products like buying an automobile and acknowledged that some controversial issues, gamesmanship, and outright bad behavior by some stakeholders have driven regulations like the No Surprises Act and that the next few years will be “very interesting” in terms of establishing common ground between healthcare’s stakeholders.

Listen here to Andrew Cone share context for establishing common ground among stakeholders. [11:32 – 13:31]Finding Common Ground Among Payers, Providers, Plan Members, & Patients

Value-based Care Programs Support Common Ground

One participant, a leader of a physician organization, shared her perspective that reducing or eliminating ongoing and often arbitrary changes to provider payments by payers and moving to more fixed, regular payments found in value-based payment programs would go a long way toward establishing common ground among healthcare stakeholders and reduce or eliminate the gamesmanship sometimes played.

It was noted the larger impact and ongoing challenge related to regional differences in care patterns and related reimbursement rates. And the challenges associated with defining levels of care at expected levels and consistently delivering those care at agreed-upon levels.

Listen here for additional impacts on establishing common ground. [19:25- 20:11]

New and Increasing Administrative Burdens Impact Costs and Payment Integrity

One participant shared their experience with increased costs associated with providing preventative care to patient populations vs. reactive care to a subset of a patient population. Others in the roundtable noted increased – and new costs – associated with identifying individuals in need of preventative services, capturing and reporting value-based measures, and identifying and accessing correct plan and community-based resources on behalf of their patients.

RELATED: Surprise Billing and the Impact for Payors

The Right Information at the Right TimeThe Right Information at the Right Time

Increased levels of provider interaction with plans on behalf of their patient population were identified as a recurring cost driver. One health system leader both praised and bemoaned the challenge of identifying and complying with different clinical care guidelines in markets served by multiple plans. She shared how each plan dictated different clinical guidelines and procedures and the fact that coverage for many services – particularly those associated with certain specialties like cardiology – was hard to ascertain, often not a covered benefit, and ended up being a patient responsibility frequently borne by the provider.

The ability to accurately identify benefits and reimbursement amounts on a timely basis – combined with clear clinical guidelines – was identified as a key means to control overall costs while at the same time doing the best for the health and well-being of the patient/member.

Length of Time a Person Remains with a Single Payer/Plan

One individual associated with a health plan noted the hesitance of funding preventative care for plan members who may not remain with the plan for more than a short period of time. For payers and care providers in risk-sharing arrangements, the cost of preventative care interventions is not typically recouped in a plan year.  They noted the likelihood of benefits associated with proactive care accruing to subsequent plans and the need to compensate clinicians and payers for delivering preventive care whose benefits are derived over multi-year periods. A topic for future discussion would be to explore the policy levers that could help to address this issue.

Impact of No Surprises Act on Provider Networks and Payment Integrity

The roundtable transitioned the discussion to the No Surprises Act where participants discussed what impact the No Surprises Act might have on the future of provider networks and reimbursement. MultiPlan’s Kurt Fullmer shared a quick overview of the Qualified Payment Amount component of the No Surprises Act and participants continued discussing the following related considerations:

Qualifying Payment Amounts as Regional Values Subject to Negotiation

QPA’s are regional values set by both providers and payers in a particular area that will be subject to a ‘baseball-style arbitration process if not mutually accepted by providers and payers.

RELATED: What is a Qualifying Payment Amount?

Compliance with State vs. Federal Regulations & PolicyQualifying Payment Amounts as Regional Values Subject to Negotiation

The need to understand and reconcile the federal No Surprises Act with state-level regulations was also discussed. One participant, a finance leader for a health system in southern California where out-of-network billing and payment law AB 72 has been in effect since 2017, noted ‘little to no non-compliance’ and expected the same with the No Surprises Act. Another participant, a leader at a PPO & IPA in the state of Washington, noted a similar experience with that state’s Balance Billing Protection Act that went into effect in January of 2020.

Removing the Patient from the Middle of Payer-Provider Payment Disputes

Kurt offered that in the interest of goodwill and patient experience, payers and providers may want to remove the patient from any payment dispute process as soon as possible.

Will Administrative Cost of Independent Dispute Resolution Force Providers to Join Networks?

While two participants noted that disputes are rare in their states which have already implemented surprise billing regulations, they and other participants agreed that direct costs associated with the dispute resolution process – and indirect costs associated with patient experience – are not insignificant and would be a consideration by any stakeholder entering dispute resolution.

One participant proposed that costs associated with dispute resolution – both direct and possibly more so with indirect patient experience costs and pressure from health systems – may force many currently non-contracted providers to join plan networks. Another participant disagreed and noted the ongoing physician shortage exacerbated by the pandemic supports non-contracted providers’ reluctance to join networks.

What Enablers Must Be Achieved to Realize Fair & Equitable Payment

The final topic Ferris presented to the roundtable was to solicit perspectives and feedback on what enablers need to be in place to achieve the overall goal of a fair price for a fair service in the most frictionless way possible. Participants agreed that while regulations cannot be ignored, that establishing common definitions, increasing meaningful collaboration and understanding between payers and providers, and working together to build transparent provider networks are primary enablers to achieve fair and equitable payments that address patient needs.

Listen here to Andrew Cone on the need for standard definitions as enablers of fair and equitable payment. [40:40 – 42:28]

Building a Fair and Equitable, Structurally Sound Payment System

If nothing else, this first roundtable on payment integrity and provider reimbursement clarified that the healthcare payment system remains broken with several long-standing structural issues that must be addressed. HCEG’s Ferris Taylor proposed that healthcare needs a solid, ‘concrete’ payment system foundation capable of withstanding the ongoing ‘huffs and puffs’ of various Big Bad Wolves involved with the current payment system: cost-shifting between stakeholders, misaligned incentives, unfair market pricing leverage, complex subsidies, and an increasing number of often ill-defined and conflicting government regulations and mandates – among other things.payment integrity value-based-care

More on Payment Integrity & Provider Reimbursement

payment integrity data and analytics costs and payment hcegWe appreciate Andrew Cone and Kurt Fullmer as thought leaders from our Focus Area Partner MultiPlan and look forward to our next roundtable on Payment Integrity: Data & Analytics for Costs & Payment. In this second roundtable on October 20th at 3:00 Pm ET / 12:00 PM PT, we’ll discuss more specific considerations and practical approaches to building a fair and equitable, structurally sound healthcare payment system.  Leaders of health plans, health systems, and care provider organizations are invited to join.  Request an invite here

Learn more about other Focus Area Roundtables here and consider joining our upcoming webinar series where information and thought leader insight and opinion of healthcare executive priorities will be presented.

If you’re not already a subscriber, join our newsletter of 5000+ other healthcare leaders and changemakers.

RELATED: Payment Integrity: Supporting Frictionless Services & Outcomes at Fair Prices

Payment Integrity. Payer Provider Reimbursement. Fair Price. Accuracy. Appropriateness. Timeliness. MultiPlan.

Payment Integrity: Supporting Frictionless Services & Outcomes at Fair Prices

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Historically, payers and providers have maintained ‘arm’s length relationships’ with each party acting in accordance with what they deemed their own best interest. Both parties were wont to hold on to data and processes each deemed proprietary to their business model. Or if shared might be harmful to their market position and operating margins. At worst, payers and providers may engage in antagonistic relationships and point fingers at each other when their members and patients complain. Nowadays with the increasing adoption of value-based payment models, mandates such as the Transparency in Coverage Rule and No Surprises Act, and the entry of non-traditional payers and service providers, it’s critical that payers and providers collaborate with each other, share information in ways beneficial to everyone involved, and recognize their mutual survival depends on using data and technologies to offer a fair service at a fair price in the most frictionless way possible.

Fair Service at a Fair Price in the Most Frictionless Way Possible

There are many considerations, challenges, and actions involved with defining what constitutes a fair service and a fair price – and several traditional and emerging points of friction between stakeholders that must be acknowledged and addressed. The No Surprises Act and the Information Blocking rule in the 21st Century Cures Act are examples of broad regulatory attempts aimed at reducing payer and provider friction with healthcare consumers and patients. Additionally, the increasing use of telehealth services, changes in CMS reimbursement for various settings including home health and skilled nursing facilities, and continuing growth in the use of high-cost drugs are just a few of the reasons for adopting payment integrity programs.

RELATED: Surprise Billing and the Impact for Payors

Payment Integrity: Balancing Cost Savings & Reducing Provider AbrasionPayment Integrity. Payer Provider Reimbursement. Fair Price. Accuracy. Appropriateness. Timeliness. MultiPlan.

It should be no surprise that the amount paid for a specific healthcare service – or outcome in the case of value-based care – can be a key point of friction between payers and providers. Accuracy, appropriateness, and timeliness comprise individual legs of the three-legged stool of fair price. And each of these legs presents specific technical, clinical, and organizational challenges that payers and providers must understand and address – whether in a fee-for-service or value-based arrangement and whether paid retrospectively or prospectively.

To build a strong foundation supporting fair services at fair prices in the most frictionless way possible, payers and providers must balance the maximization of savings from payment integrity programs with minimizing provider abrasion.

RELATED: Trends that are re-shaping payment integrity strategies

Get Answers to Your Questions & Share Your Insight & Ideas

Our 1st Focus Area Roundtable on Payment IntegriPayment Integrity. Payer Provider Reimbursement. Fair service at a fair price in the most frictionless way possible. Transparency in Coverage Rule. No Surprises Actty offers a forum for all participants to discuss topics and ask questions pertaining to reimbursement, payment integrity, and provider networks including:

  1. How can providers and payors find common ground in terms of setting prices and reimbursement?
  2. In what ways will the No Surprises Act change the future of provider networks?
  3. How must payment integrity programs evolve to ever be considered by providers as fair?

Join other healthcare leaders and changemakers on Thursday, September 9, 2021 at 11:00 AM PT / 2:00 PM ET for the first of a series of roundtables facilitated by our Focus Area Partner MultiPlan. Request your invitation today.

Impact of Healthcare Policy. Legislation. ACA exchange marketplace. Individual Small Group Market. SEP. extended enrollment. Subsidy. American Rescue Plan. open enrollment period. Softheon.

Impact of Healthcare Policy on ACA Marketplace – Leadership Discussion

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The new administration and the pandemic have significantly impacted the United States healthcare delivery system with many changes to health care regulations and policy – particularly in regards to the Affordable Care Act (ACA). In an effort to support the discussion of the challenges, issues, and opportunities facing healthcare leaders and changemakers, the HealthCare Executive Group has hosted a series of Focus Area Roundtables. The 3rd roundtable on Healthcare Policy & the ACA took place on August 12th, 2021 with 16 leaders of health plans, care provider organizations, and other stakeholders sharing information, insight, and opinions on the impact of healthcare policy on the ACA and the healthcare delivery system.

See recaps of first roundtable and second roundtable on Healthcare Policy & ACA held in March and May.

This post recaps this roundtable moderated by HCEG Executive Director Ferris Taylor and supported by Kevin Deutsch, General Manager & SVP of Health Plan Cloud at Softheon, our Focus Area Partner for Healthcare Policy & ACA.

Webinar – Recapping Roundtables & Impact to 2022/2023 ACA Marketplace

Something Old, Something New: Two Health Plan Executives Share Their Experiences in the ACA Marketplace.Join us on Tuesday, Sept 21 at 1:00 PM EDT for “Something Old, Something New: Two Health Plan Executives Share Their  Experiences in the ACA Marketplace as a Veteran & a New Entrant.” Leaders of two health plans operating on the ACA Marketplace will discuss topics raised during the string of Healthcare Policy & ACA roundtables AND their experiences with exchange-related services, cost savings, compliance, member growth, privacy, and more.

Impact of Healthcare Policy on ACA’s Individual and Small Group Market

Ferris kicked off the discussion by asking Kevin Deutsch to share his perspective on how recent legislation has impacted the ACA – especially the individual and small group market. Kevin shared some information on new enrollment from the special extended 2021 enrollment period that started in February; and the impact of changes to subsidy levels in the favor of the consumer.

2.5 Million New Individual Exchange Members Added Since January 1st, 2021

Some of those in the special enrollment period were those that were affected by COVID, may have lost their jobs, and went on to the ACA Exchange to get individual insurance. And there was another change that eliminated the 400% federal poverty level – the Cliff – at the end of the subsidy. And made that a longer tail of enrollees. And it may be too early to get any sense of what types of other people have come on in this 2.5. Million.

Kevin offered that upcoming health plan rate filings for 2022 should reveal quite a few new payers in the marketplace – as enrollment number grows and the government becomes responsible for a greater share of overall costs of coverage.

2021’s Special Enrollment Periods & SubsidiesACA exchange marketplace. Individual Small Group Market. SEP. extended enrollment. Subsidy. American Rescue Plan. open enrollment period.

Another participant elaborated on the impacts of the American Rescue Plan’s elimination of the subsidy cliff and the expansion of subsidies, as well as impacts from the extension of the open enrollment period. He noted that actuarial/risk management functions are having to rise to a new level and more effectively communicate the pre-COVID, COVID, and post-COVID activity in terms of claims and utilization.  The fact that more enrollees have been drawn to the ACA’s individual market via the exchange should add financial stability standpoint with a more sizable, stable risk pool.

After one participant noted a CMS 2022 notice proposing to extend the annual open enrollment period from 45 days (currently November 1st to December 15) to 75 days (November 1st to January 15). This proposed 30-day extension received quite a bit of discussion. One participant noted this as a potentially good change in that December is typically viewed as a holiday month and that’s not when people are focused on their health care. Another noted that many individuals will just procrastinate. Another noted a concern about the potential for a shortened coverage period for those enrolling in January.

A significant part of the roundtable discussion revolved around challenges with inadequate explanations of and consumer understanding of changes to enrollment periods and subsidy levels. All participants noted that payers, brokers – and even the provider community – need to help increase consumer literacy regarding subsidies and financial impact.

Listen here for more on the impact of healthcare policy on ACA enrollment. [3 mins 49 secs]

Increased Retroactivity Scenarios & More Complex Reconciliation

Participants discussed the impact that special enrollment periods and extending enrollment periods will have on increased retroactivity and reconciliation scenarios health plans must deal with. Another shared that if you look at 2021 in particular, many members are switching between plans at a greater frequency than what’s consistently been the case with ACA enrollees prior to the pandemic. Discussion continued with operational and back-office challenges health plans are going to continue to face in relation to all these changes.

Ongoing Issues with Member/Patient Literacy – Enrollment and AccessHealthcare consumer literacy. Education. Enrollment periods. Subsidy. Open enrollment period.

Participants discussed how increased choice and opportunity created by extended enrollment periods and increased subsidy levels have not been well understood by individuals and have amplified the need for health plans, brokers, and even care providers to help increase healthcare literacy among members, consumers, and patients. One participant noted that the industry as a whole has got a lot of work to do to help improve member literacy and experience.

Lack of Consumer Awareness of Increased Subsidy Levels

Kevin noted that the 30-page ACA application for individual insurance contains one question about subsidies changed as part of the American Rescue Plan Act. And that CMS hasn’t done much at all in the awareness and education area to help individuals understand what’s available to them.  And shared that he thought that is part of why CMS is going to auto-reallocate subsidies to individuals who haven’t gone out and done it. Listen here as Kevin Deutsch explains challenges with recent subsidy changes. [1 min 09 secs]

Taking Time to Educate Consumers & Health Plan Members

One participant recalled that the Kaiser Family Foundation provided an ongoing or monthly outreach and learned that 35 to 40 percent of people did not know when open enrollment started, didn’t know what it meant, and didn’t know that it had an end to it. The participant opined: “I don’t think that’s on the consumer, that’s on the industry.”

In response, another participant shared that a primary directive at his company – a community-based health plan organization – is to make a special effort for its members to receive and understand what options and opportunities are available to them and to assist their members with access to care.

Educating Members About Coverage & Access: Taking a Page from the Medicaid Segment

Participants discussed the importance of educating enrollees with dedicated community outreach that incorporates an appreciation of the social determinants impacting enrollees. One participant, a health plan leader, emphasized that health plans, whether for-profit or non-profit, should dedicate a portion of their operating budget to educating their members in a sustained fashion on how members can make the most of the benefits that they receive from a health plan. Listen here to a health plan leader on the need for plans to educate plan members [2 mins 23 secs]

Extending Enrollment Periods and Human Nature to Procrastinate

This same participant continued sharing the importance of doing a better job of providing people with good information about enrollment, financial costs, and subsidies, and facilitating access to care was universally acknowledged by all participants. This participant, a health plan leader having P&L responsibility for 300k lives over a 10-year period noted that anywhere from 25 to 30 percent of their enrollment for net, new enrollment came in the last three days of the eligible period. He closed out his comment by stating “So, if you want to talk about procrastination, there it is.” Roundtable participant shares on the impact of extending open enrollment periods here. [1 min 5 secs]ACA exchange marketplace. Open Enrollment Period. Special Enrollment Period. Annual Enrollment Period. OEP. AEP. SEP.

Impact of Healthcare Policy: State vs. Federal and State-by-State Variations

Two participants – one operating in New York and the other in Hawaii – discussed the importance of addressing enrollment periods, premium rates, subsidy amounts, eligibility levels, and access at the state-by-date and federal vs. state levels. In New York, which operates a state-based exchange, enrollment periods, eligibility and financial subsidies are more generous at the state level and not impacted by changes at the federal level. While in Hawaii, a state operating on the federal exchange, plans must comply with less generous federal regulations.

RELATED: How the End of the Public Health Emergency (PHE) will Impact Health Insurers

Variances in Access to Care – To Be Addressed by Healthcare Policy?

Both the New York and Hawaii-based participants noted that access to care is a challenge and that enrollees who expect to have access to whole-person care will have a difficult time accessing care. Hawaii has a severe shortage of PCPs and New York suffers from a similar challenge in the rural, western New York area. Hawaii has cost of living issues and access in Western New York is similar to many rural areas experiencing shortages. These shortages existed pre-COVID and have gotten worse with the pandemic.

One participant noted that provider network teams are struggling to add physicians and they have even had to help subsidize some of the providers in the area to keep them afloat, especially PCP’s.

Behavioral Health Issues and Lack of Providers

One care provider participant noted the increased need for behavioral health services and the dearth of providers – a need that existed prior to the pandemic and which, as widely reported, has gotten worse due to the pandemic. While not directly related to the impact of healthcare policy on the ACA, a short discussion on the importance of considering behavioral health and social determinants of health data such as financial status and where people live. Listen here to participants discuss care challenges related to location and access. [4 min 39 secs]

Release of Pent-Up Demand – Delays Creating Advanced Medical Issues

Ferris asked participants whether they are seeing patients they haven’t seen before? And whether these new enrollee patients were more healthy or less healthy.

A participant noted that the second-quarter financials of most of the health insurance companies indicated a significant decline in earnings as many more patients and consumers have started to come in for care. And that some health systems have many more patients coming in, especially patients with chronic conditions patients with cancer. Many of these patients, unfortunately, put off screenings, put off a number of therapies. And so, we have seen a big increase in patients coming in for screenings.

She also noted a push from a lot of organizations and health systems to get patients in for screenings. And that, especially in the oncology space, providers are seeing patients coming in with more advanced disease because they have put off care during the pandemic and they’re coming in with more progressed disease and therefore having more challenges. Listen here to participants discuss delays in care creating sicker, more costly patients. [1 min 29 secs]

Telehealth Dropping from Peak Usage & Non-Traditional Stakeholders as Gateways to Access

In response to the increase in patients with advanced stages of disease due to not being seen over the pandemic, another participant reminded the roundtable that one of the positive things that have come out of COVID is the growth and wider acceptance of telehealth and telemedicine and its significant uptake – even with recent pullbacks from peak telehealth usages during the pandemic.

Impact of Healthcare Policy. Legislation. ACA exchange marketplace. Individual Small Group Market. SEP. extended enrollment. Subsidy. American Rescue Plan. open enrollment period. Softheon. Impact of Healthcare Policy. Legislation. ACA exchange marketplace. Individual Small Group Market. SEP. extended enrollment. Subsidy. American Rescue Plan. open enrollment period. Softheon.

Listen here to participants discuss telehealth and non-traditional stakeholders. [2 mins 25 secs]

Chronic Care Management – Digital Care to Manage Transitions of Care

One participant noted the opportunity for using telehealth and virtual care technologies in the area of Chronic Care Management to better manage available resources and prevent costly transitions of care. He described digital care technologies can be used to anchor individuals in the home and provide care across the care continuum while preventing individuals from re-entering the care cycle – particularly more costly, often less-effective settings like the emergency department. Hear more here about leveraging digital care technologies to achieve Quadruple Aim [3 mins 39 secs]Intelligent Care Management Technology: Driving Alignment Towards the Quadruple Aim

Click here or the above image to learn more about Intelligent Care Management Technology

Pandemic-Driven Impact of Healthcare Policy: Innovation, Consumer-Centricity, & Access to Care

One participant related that prior to the pandemic there was a lot of pushback from their provider community when the health plan wanted to move toward increasing the use of telehealth. Then the pandemic started and there was much more acceptance of not only telehealth providers but providers offering virtual visits themselves with their own practices.

He noted that one of the good things that came out of the pandemic is that the entire industry, across the entire spectrum, has started to become more willing to be innovative and experiment with things. And be a lot more focused on members. Listen here to a health plan leader on what plan members need beyond health care [1 min 37 secs]

“I’ve spent my whole career listening to strategy folks talk about how this year we’re going to put the focus on the member. This year we’re going to be consumer-centric this year. We’re going to be member-centric. It’s sort of a challenge because when I make board presentations or do advisory work, we hardly ever talk about the member.” – Health Plan Leader

Webinar – Recapping Impact of Healthcare Policy & ACA Marketplace in 2022 & 2023

Join us on Tuesday, September 21, 2021, at 10:00 AM PT / 1:00 PM ET for Something Old, Something New: Two Health Plan Executives Share Their Experiences in the ACA Marketplace. In this webinar, two health plan executives will join Ferris and Kevin to address key challenges, issues, and opportunities raised in the roundtable series and which will help ensure health plan organizations are well-positioned for growth in 2022 and 2023 as subsidies expand, programs stabilize, and opportunities.Something Old, Something New: Two Health Plan Executives Share Their Experiences in the ACA MarketplaceIf you’re an executive/leader of a health plan, health system, or healthcare provider organization, consider joining one or more of our Focus Area Roundtables. We currently have a number of roundtables based on 2021 HCEG Top 10+ focus areas scheduled with additional roundtables being planned.

For more insight and information on the challenges, issues, and opportunities facing healthcare leaders, subscribe to our newsletter and connect with us on Twitter and LinkedIn.

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Intelligent Care Management Technologies: Key Considerations & Opportunities

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As the healthcare delivery system continues to embrace value-based care and payment models, a number of factors are driving the adoption of intelligent care management technologies by health plans and other payers. Healthcare consumers, patients, and employers are recognizing the importance of whole-person care and demanding more cost-effective, personalized engagement. Traditional service settings are changing with large increases in telehealth and digitally based services. And more and more non-traditional providers are offering medical and non-medical services – often in the home. All these factors – and others – demand an operating ecosystem with intelligent care management that supports scalable collaboration and coordination between all stakeholders.

Collaboration and Coordination: Foundation of Whole-Person, Value-Based Care

A digital ecosystem that supports clinical, financial, and administrative needs of all stakeholders in a collaborative and coordinated fashion is a foundational component needed to deliver whole-person care – whether those services are provided under fee-for-service and value-based care payment models.

No longer is it sufficient for just physicians, clinicians, and traditional care managers to have access to patient information and be involved with care planning and delivery. Nowadays, the patient themselves, their caregivers and family members, and other new types of care coordinators and service delivery organizations must be included. Additionally, multiple administrators and supervisors play increasingly important roles in care planning, service delivery, and post-care coordination and management. The ability to connect, support, and manage all these stakeholders in a collaborative and coordinated fashion is critical.

RELATED: Optimizing Care Management Through Whole-Person Care

Why do Health Plans Need Intelligent Care Management Technologies?

Health plans have historically collected and received patient data from the majority of the care providers their members are seen by. And, starting in January of 2023, the Interoperability and Patient Access final rule (CMS-9115-F) requires providers to send their entire patient medical record to a patient’s current health plan. Based on this history and new regulations, health plans that integrate, support, and scale intelligent care management technologies to support 360º whole-person care – particularly under value-based care models – can advance their market position by incorporating additional data and entities in their care management facilities:

  • Social determinants and behavioral health issues
  • 3rd party data sources and insights from advanced analytics like machine-learning and artificial intelligence
  • Non-traditional entities including community-based organizations and other non-medical service providers

RELATED: Health Plans as Primary Connection for Patients & Healthcare Consumers

Key Components of Intelligent Care Management PlatformsIntelligent care management technologies. Value-based care models. Whole-person care. Patient engagement. VirtualHealth HELIOS.

And health plans utilize many different platforms and point solutions to support their members and the provider networks that serve their members. These operating ecosystems are almost always a combination of commercial off-the-shelf, bespoke, and point solutions – and hybrid platforms cobbled together over many years. Regardless of the composition, intelligent care management demands certain core capabilities – all of which should support one or more points of the Quadruple Aim:

Better Outcomes & Population Health

  • Built-in utilization management tools with access to a broad set of member/patient data
  • First-level assessments that automatically drive subsequent workflows
  • Ability to access and coordinate admissions, discharges, and transfers (ADT) events
  • Out-of-the-box, configurable, validated assessments incorporating non-clinical risks

Improved Patient Experience

  • Ability to manage and maintain close interactions with individuals across every setting of care
  • Built-in, HIPAA-compliant services including telehealth capabilities
  • Targeted, proven, and personalized approaches to manage the health of various populations on a timely and scalable basis
  • Integration with IVR and third-party digital technologies, wearables, and connected devices

Reduced Cost of Care & Better Financial Outcomes

  • Multi-source data interfaces and aggregation
  • Robust rules engines supporting clinical, administrative, and financial processes
  • Intelligent application of robotic process automation (RPA) tools
  • Integrated with community resources and non-traditional social determinants data

Improved Clinician Experience/Care Team Well-Being

  • Advanced analytics proactively integrated into payer and provider workflows
  • Data and services that support and enhance provider care delivery services
  • Intelligent insights: event-driven and delivered across the care management continuum
  • Automated, workflow-enhancing services/tools – particularly in utilization management and related services

Non-Functional Aspects of Intelligent Care Management Technologies

Realizing the benefit that intelligent care management technologies can deliver is not always an either/or decision and each health plan has unique needs. In addition to the above and other key functionality and considerations, there are several non-functional considerations to consider when evaluating intelligent care management opportunities:

  • Timelines for implementation and the ability to rapidly deploy
  • Ability to retain and leverage existing data and assets
  • Product configuration capabilities
  • Ability to swiftly adapt to new business opportunities and stay compliant with evolving regulations
  • Potential to incorporate new, best of breed applications

RELATED: Top 3 Capabilities Health Execs Need in Care Management Technology

More About Intelligent Care ManagementIntelligent care management technologies. Value-based care models. Whole-person care. Patient engagement. VirtualHealth HELIOS.

To learn more about how intelligent care management technologies can help health plans achieve the Quadruple Aim, join us on October 7, 2021 at 12:00 PM PT / 3:00 PM ET for an HCEG Webinar Series event: Intelligent Care Management Technology: Driving Alignment Towards the Quadruple Aim.

HCEG leader Ferris Taylor and Sue Powers, a long-time executive of VirtualHealth, will discuss select intelligent care management technologies and how they can help health plan/payer organizations compete in our rapidly evolving and often uncertain health care delivery system.Provider Onboarding Processes. Appian. The Doctor Can’t See You Now: New Ways to Speed Up and Improve Provider On-Boarding. HCEG Webinar Series Event. Healthcare Executive Group. Low-code platforms. Provider On-Boarding onboarding. physician revenue, provider directory inaccuracies, denials. revenue cycle. credentialing verification. RPA robotic process automation AIRegister now for this live webinar and bring your questions for the Q & A session at the end of the webinar. All registrants will receive a recording of the webinar.

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Practical Interoperability Part 2: Trust, Workflow, Value-Based Care Models, & More

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‘Practical Interoperability’ means different things to different healthcare stakeholders. In the HealthCare Executive Group’s first Focus Area Roundtable on Interoperability, leaders associated with health plans, care providers, and organizations supporting the healthcare system discussed what practical interoperability means to them. Addressing barriers to interoperability and use cases with the most potential to increase interoperability was a primary focus of the roundtable with highlights shared in the first post recapping the roundtable titled ‘Discussing Barriers to Healthcare Interoperability, Use-Cases, and More.’ This second post shares additional highlights including increasing adoption of use cases, the importance of trust among stakeholders, interoperability’s increasing impact on value-based arrangements, and workflow considerations – particularly in terms of balancing the amount of information exchanged by payers and providers.

Read Part 1 of the recap of this first Focus Area Roundtable on Interoperability here.

Importance of Establishing & Maintaining Trust to Overcome Barriers to Practical Interoperability

Building on discussion of the importance of health plan-provider collaboration and which stakeholders are best positioned, qualified, and equipped to own specific interoperability use cases, HCEG’s Ferris Taylor noted the abundance of EMR’s, robust data sets that increasingly include structured clinical data, and analytical capabilities that weren’t available 12-15 years ago. These data and analytics, along with mandates on transparency and interoperability – particularly electronic prior authorization and pricing data – are forcing stakeholders to increase trust among themselves and other 3rd parties.

Ferris asked Tim Capstick, Regional Vice President of Health Plans at Surescripts, to frame the discussion of developing trust to unlock the value of increasing practical interoperability.

Developing a Trust Framework to Unlock the Value of Existing Healthcare Data AssetsTransparency in Coverage Mandate. No Surprises Act. health plans, health systems, healthcare providers. compliance-related activities. Data Standards, Data Collection & Operational Considerations

Tim set the context for roundtable comments by sharing how well-defined standards, clearly understood use cases, and trustworthy partners serve as the essential foundation to maximize business model benefits of increased interoperability. Tim emphasized: “We have to be able to trust whoever’s going to sit in the middle – or bring these entities together. We’ll have to be able to trust each other and make sure that we know and trust what each other are going to be doing with this information.

Listen here for more on establishing trust to unlock the value of healthcare data

RELATED: Building Trust is Essential to Transforming the Healthcare System

Establish Trust by Consistently Providing Quality Information That Returns Value

One participant representing a research organization shared that standards – particularly FHIR – will help with advancing practical interoperability once the data content, elements and formats of these standards are better understood.

Participant Denny Brennan, Executive Director and Chief Executive Officer of HCEG partner Massachusetts Health Data Consortium (MHDC), weighed in on the importance of by sharing that MHDC is creating an implementation guide combining DaVinci-compatible payer data and clinical data exchange standards related to prior authorization.

Denny noted that payers and providers have a great deal of work getting their digital house in order and making the necessary data available to accelerate instantaneous or close to instantaneous prior authorizations for services that today are difficult, arduous, and don’t require a huge amount of clinical intervention, if anything, to make the decision.Healthcare Price Transparency Price Transparency Regulations & Compliance, Policies, Programs, & Tools, Data Standards & Operational Considerations

Listen here for more on the importance of providing quality data to healthcare providers

See Price Transparency Data Standards & Operational Considerations from a recent roundtable in Price Transparency facilitated by our Focus Area Partner HealthSparq.

Balancing Amount of Data Shared with Providers – Increasing Impact of Value-based Arrangements

Other discussions involved challenges, issues, and opportunities regarding interoperability’s impact on the day-to-day workflow of healthcare stakeholders – particularly in terms of how care providers are accessing information and what information is being presented. The balance between providing too much information that can overwhelm care providers, administratively burdens them, and inhibits their ability to do what they need to do and responding to provider requests for more information to make care decisions were discussed. Participants noted value-based arrangements and risk-based reimbursement models are clearly an impetus for increased interoperability and drive desire from the provider community for more information. Being mindful of the process workflow of care providers, what information is inserted into the workflow, and how that information is inserted and accessed was identified as key considerations.

RELATED: How Health Plans Can Best Support Provider Organizations Address Barriers to Practical Interoperability

The Importance of Breaking Workflow to Include Business Partners

Roundtable participants made clear that accommodating care provider information demands – whether under traditional FFS or new value-based payment models – requires a thoughtful change to provider workflows. In addition, compliance with interoperability mandates and realizing practical interoperability’s greater benefits means all stakeholders will need to break their routines and [modify] their workflows to include partners.

“Stakeholders don’t have to do this themselves if they can get out of the adversarial zero-sum game that, if we share data with providers, or we share data with health plans, they are going to use those data against us or whatever scenario comes to mind. There’s a lot of money that’s being swept off the table by IT vendors who are offering niche services that ultimately never get used.” – Roundtable Participant

As shared in the Part 1 recap of the roundtable on interoperability, if providers invested in better collaboration with their payers, they might reduce their investment in the technologies to support processes they thought they were going to do entirely by themselves.

Listen here for more on breaking business partner workflow to reduce overall IT investments

Interoperability Vendors Serving the Healthcare Market – a Darwinian ExperimentDarwinian experiment interoperability-related initiatives, programs, and applications.

Participants shared various comments about increasing the adoption and evolution of interoperability-related initiatives, programs, and applications.

One participant shared his observation that, on the intervention side, increased interoperability is empowering many great third-party companies that are already doing great work around mobile engagement, disease management, and so on.

“There’s a whole bunch of them. There’s been a sort of Darwinian experiment of all these different vendors about what approaches to take and we’re starting to see some rise to the top; to create the ability for them [providers] to sort of socket in a secure way and play on the platform and do things for the benefit of patients.”

Another shared that healthcare stakeholders have a collective obligation to create a competitive environment for the adoption of practical interoperability:

“I think when we talk about interoperability, we have just not a responsibility but really an obligation to create a competitive environment where they can come and play and let the best continue to rise to the top.”

And another shared a suggestion to healthcare providers who think they can avoid sharing their healthcare data.

One of the steps that we have to really focus on in terms of what do payers and providers have to do is: stop thinking you have to do everything yourself. You’re going to have to share data. Forget about arguing about that. Forget about it. You’re going to have to share everything. The deal is done. It’s over. You’re going to have to be transparent, get over it, stop complaining about it.”

And now, healthcare requires payers and providers are going to have to really start thinking about creating new, collaborative business models that engage consumers. And if they don’t do that and each go after the consumer in their own way, they’re just complicating the problem we have today which is: I want to go to one place to get all my health data. The fact that it’s a health plan as envisioned in the regulation should not preclude any progress.

Quality Measures: Data Requirements, Costs, & Impact of Upcoming Changes

A participant from a small health plan noted the number of new hybrid measures related to telehealth services and how interoperability mandates and related initiatives will impact provider collection of quality measures and submission to health plans; particularly as the CMS deadline for transition to all-digital quality measures takes place in 2025 and information currently being collected goes away.

Sharing Information – It’s the Law & The Right Thing to Do

This participant representing a small health plan expressed concern about the number of EMR systems in use at health systems, the overall lack of awareness, understanding and adoption of interoperability mandates among the provider community, and the challenges that present health plans – particularly smaller health plans – with accessing data from health systems.

She mentioned the cost impact of both complying with interoperability mandates and how some providers and health systems charge for access to data housed in their individual EMR’s.

“We’re sitting here knowing that our entire world is going to digital, knowing that we have to get to digital, seeing interoperability as one opportunity for everybody collectively to get to digital. But the adoption rate is The Big Question in my mind.”

Listen here to the leader of a small health plan share insight on accessing data

Information Blocking – Serious Consequences for Non-Compliance

Information Blocking. Section 4004 of the 21st Century Cures Act. Electronic Health Information (EHI). USCDI Version 1. Regulations. Interoperability

Source: Office of the National Coordinator for Health Information Technology (ONC)

Existing regulation concerning Information Blocking (Section 4004 of the 21st Century Cures Act) was raised with one participant noting that charging fees for accessing, exchanging, or using Electronic Health Information (EHI) – with exception per 45 CFR § 171.302 – is a felony.  He noted that while a smaller subset of EHI data (elements defined in USCDI Version 1) is currently subject to Information Blocking through October 5th, 2022, regulations expanding those data elements to USCDI version 2 are quickly approaching and the regulated community should make all EHI available as if the scope of EHI were not currently limited to Version 1.

Patience for Non-Compliance with Information Blocking Regulations is Decreasing

This topic of discussion was ended with this participant saying:

“And CMS and the [Biden] Administration have shown absolutely no patience whatsoever with that stance. So, I think health plans who were finding themselves running up against EMR’S who are trying to monetize data and the availability of data from their records, have the weight of the law behind them. Providers who try to monetize their data exchanges with health plans directly is not okay unless it’s purely at cost or something very close to at cost if it’s an extraordinary effort. And going forward it’s not going to command a very high premium to get data from the provider who’s treating a member.”

Listen here to a healthcare data expert on provider reluctance to share data with health plans

Learn More About Practical InteroperabilityPractical Interoperability. Electronic pre-authorization. Surescripts. HealthCare Executive Group. HCEG. Focus Area Roundtable. health plans, payers.

On September 8th, 2021, leaders of health plans, health systems, and provider organizations will have the opportunity to discuss the real-life initiatives, programs, applications, and technologies their organizations are considering, implementing, or currently using to address the challenges, issues, and opportunities recapped here and in the first post of this two-part series.  Leaders of health plans, health systems, and provider organizations are encouraged to request an invite here.

Special thanks to Ashley Clark and Tim Capstick of our sponsor Surescripts for sharing their unique insight in this roundtable. For information on any of the topics presented in this post, contact Tim Capstick or Ashley Clark.

To receive additional information on interoperability and other healthcare leader priorities presented on the 2021 HCEG Top 10+ list, subscribe to our newsletter and follow us on Twitter and LinkedIn.

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Discussing Barriers to Healthcare Interoperability, Use-Cases, and More – Part 1

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‘Interoperability’ – particularly between health plans and care providers – has been a high priority of healthcare executives for years. It ranks #6 on the 2021 HCEG Top 10+ list and has an impact on almost every area of healthcare. And recent, still evolving mandates regarding data transparency, information blocking, changes to current HIPAA regulations, and interoperability have placed significant challenges upon the health plans, provider organizations, and the technology partners serving the healthcare industry. Forward-thinking stakeholders are not considering mandates as barriers to healthcare interoperability but rather viewing compliance with mandates as opportunities for ensuring the ongoing viability of their healthcare business models.

In our first Focus Area Roundtable on Interoperability held Tuesday, July 20th, and facilitated by our Focus Area Partner Surescripts, leaders from health plans, health systems, and healthcare provider organizations shared their experience, insight, and information in a roundtable fashion on the topic of Interoperability. Surescripts Tim Capstick and Ashley Clark served as industry thought leaders providing their perspective on these interoperability-related topics, in particular from a health plan point of view.

This post presents the first part of a 2-part series sharing highlights of this first roundtable on interoperability. Leaders of health plans, health systems, and provider organizations are encouraged to participate in upcoming Focus Area Roundtables including the 2nd Interoperability roundtable on September 8th, 2021.

Read Part 2 of the recap of this first Focus Area Roundtable on Interoperability here.

Barriers to Healthcare Interoperability Payers & Providers are Encountering

HCEG’s Executive Director Ferris Taylor kicked off the roundtable by asking participants: What are the barriers to healthcare interoperability that health plans and health systems are encountering with respect to the broad topic of interoperability?

Consent Management – One of the Barriers to Healthcare Interoperability

One participant noted that when deploying interoperability solutions, one of the biggest challenges involves consent management for members and patients. Appropriately managing patient data and providing individuals the ability to weigh in on the sharing of their data is both a technical and policy problem. He noted while their organization is addressing consent management largely on their own, he expects the evolution of privacy laws in California and Europe will likely have a national impact across the United States.

Another participant shared that addressing consent management is key to the future of interoperability – not just between members/patients and their health plan and providers but also when providers are sharing information with other health systems/healthcare providers.

Listen here for more on the importance of consent management in advancing interoperability

Other Barriers to Interoperability for Health Plans and ProvidersHCEG HealthCare Executive Group focus area roundtable Barriers to Healthcare interoperability poll

Participants were presented with a list of potential barriers to interoperability and asked to select two barriers from the perspective of a health plan and a provider.

For health plans, Access to and Integrating Data Sources ranked first followed by Complex Privacy and Security Concerns.

For providers, Internal Challenges with Technology and a Lack of Knowledgeable Resources were identified as key barriers to healthcare interoperability.

Impact of Proposed Modifications to HIPAA’s Privacy Rule on Interoperability

Surescripts Ashley Clark shared that data rights are an issue her organization takes very seriously and that they’re currently looking at CMS legislation regarding expanding the definition of treatment under HIPAA and what information can be shared as medical treatment versus non-treatment. Ashley shared that pending regulation changes will likely open up a lot of doors in terms of information that can be shared on things like medication history.

Another participant shared his perspective on barriers to healthcare interoperability for payers and providers by sharing that from his vantage point he’s seeing tremendous reticence on the part of providers to address interoperability and data transparency in any deep way vis-à-vis their health plan partners; with the exception of some relationships forced by the COVID pandemic.

Who Owns Health Plan Member and Provider-Patient Data?

Health Plan Best Positioned to Own Data - HCEG-Industry Pulse Research Survey 2020

Data Ownership – 2020 Industry Pulse Report

The recent announcement by the Biden Administration to increase penalties on providers who are not making their pricing information available was identified as the first step toward breaking the long-held, culturally ingrained notion that patient care and the information generated from that critical activity belongs to the health system and to the provider community alone.  It was noted cultural acceptance – on the part of both payers and providers – that their existing business models are built on a largely zero-sum game is a large barrier that must be overcome in order for practical interoperability to be widely adopted.

Note: Respondents to the 2020 Industry Pulse Report shared their take on data ownership between payers and providers. See survey results in the graphic on the right.

Listen here to a roundtable participant discuss data ownership among health plans and providers

“Culture eats technology. Culture eats strategy. Culture eats operations. Culture even attempts to eat policy for lunch.” – Roundtable Participant Denny Brennan – Executive Director & Chief Executive Officer of HCEG partner Massachusetts Health Data Consortium

Health Plans as Primary Connection for Patients & Healthcare Consumers

The concept of data hoarding by providers and payers was discussed along with the idea that it’s easier for health plans to surface data than it is for providers to do so. January of 2023 – just over two years away – was noted as a deadline for providers to share almost all of ‘their data’ with health plans. Per the Interoperability and Patient Access final rule (CMS-9115-F), providers will have to send the entire patient medical record to a patient’s current health plan because that health plan is responsible for moving that to the patient’s next health plan.

“I know a lot of regulators and a lot of providers around the country have not yet internalized the idea that the primary connection for the patient is going to be the health plan and that providers are responsible for providing the health plan all the clinical data that’s necessary to maintain that connection. And to inform the patient and make it possible for payer-to-payer connectivity to work.”

RELATED: Key Interoperability, Health Information Technology, and Transparency Policies

How Health Plans Can Best Support Provider Organizations Address Barriers to Healthcare Interoperability

“If I were running a medical group or a community hospital, one of the first things I’d be thinking is:

  • How do I sit down with my major payers and figure out what I can upload?
  • What am I doing that I don’t have to do that payers can pick up with me?
  • How do I cement that partnership by taking over pieces of the business that they insist on taking over that I’m better equipped to do like delivering care to the patient?

I’m the one who’s going to engage the patient. Give me tools, help my staff get trained so that the doctor doesn’t have to talk to the patient about SDOH or the doctor doesn’t have to talk to the patient about their financial exposure.”

Listen here for more on how health plans can help healthcare providers enhance interoperability

Use Cases with Most Potential to Increase Interoperability

Ferris asked participants to share their insight on which use cases might best advance interoperability and improve payer-provider-patient/consumer collaboration.

Increasing Consumer Ownership & Assisting Stakeholders Serve Their Members/Patients

A health plan participant shared that the use cases he sees that have the most impact potential are ones that lead to an increased amount of consumer ownership and activation of the health system to serve the member/patient. He noted that the process of effecting these use cases requires healthcare organizations to face some level of deconstruction. He explained that addressing barriers to interoperability in healthcare means that everyone has to have a relationship with everyone else when it comes to data – and some organizations are uncomfortable with that. So, we have more work to do.

Automating High Friction Activities & Improving Patient Engagement

Another participant shared that his organization separates use cases into two major buckets. One in the realm of automating high friction activities between payers and providers. Frequently occurring activities that can be automated and that are happening in every other industry. And the other in the realm of interventions, population health, or value-based care efforts that actually improve care like patient engagement, chronic disease management, telemedicine, etcetera.  For each bucket he emphasized the importance of each use case:

  • Being capable of being rolled out on their own and in a stepwise fashion to get to some ideal future state.
  • Having deployable value on its own and being able to stand on its own.

As an example of the bucket on the automation side, one of the first things healthcare organizations should address is auto eligibility because something like three-quarters of the calls from providers to their payers is some flavor of eligibility. And, except for a long tale of rare cases, a lot of that is totally automatable.

In a recent Focus Area Roundtable facilitated by HealthSparq, participants discussed how new price transparency mandates will likely help drive opportunities for increased engagement between providers and their patients. Read more about this potential in Payer-Provider Collaboration Critical to Meeting Price Transparency Mandates.

Reshaping Patient Relationships with Providers

Another participant shared that their personal experience is that the patient-provider relationship is typically a transactional relationship – often a negotiation on a chargemaster – and that increased interoperability seems to have the potential at least to change that quite dramatically.

Most Impactful Use Cases Identified by Focus Area Roundtable Participants

After discussing interoperability-related use cases, participants responded to a poll on ‘Which interoperabiliHCEG HealthCare Executive Group focus area roundtable Barriers to Healthcare interoperability Use Cases pollty use cases offer the most opportunity to advance patient-payer-provider collaboration?’ This question was asked from the perspective of both health plans and providers and the following were equally ranked for both health plans and providers:

  • Shortening or Automating Prior Authorizations
  • Providing Pricing Data to Patients & Providers

Electronic Prior Authorizations – Webinar on August 25th at 2:00 PM ET

Automating the processing of prior authorizations via ‘electronic prior authorization’ (ePA) – particularly in settings like the pharmacy where a patient may be waiting – can significantly enhance patient/member engagement by reducing the time between a request being made and a patient receiving care. To learn more about the Fast Prior Authorization Technology Highway (Fast PATH) initiative launched by AHIP and several health plans, consider attending Electronic Prior Authorization: The Fast PATH Towards Better Patient Care on August 25, 2021 at 2:00 PM – 3:00 PM ET.

Cutting Through Administrative Chaos by Focusing on Specific High-Value Use Cases

Surescripts Ashley Clark shared some actions that can be performed to cut through the chaos of everything that’s going on administratively at health plans and provider organizations. These included:

  • Driving adoption and usage of a limited set of use cases by getting very specific about those use case
  • How achieving success with a limited set of use cases can lead to bigger decisions across the board.
  • Being very detailed about the information that is being shared back and forth so that it’s not seen as if irrelevant information were overlooked

Listen here for more from Surescripts Ashley Clark on cutting through administrative chaos

Plans and Providers Working Together to Avoid Duplicative Efforts

One participant whose organization is closely engaged with supporting provider organizations shared that when meeting with providers and health plans they talk regularly about “You both are doing the same things, you call them the same things. They’re a little bit different but why are you both doing Population Health Management?” He commented: “I don’t understand why people who are battling it out on engaging the patient are battling it out on collaboration at the level of administering clinical process.”

Who’s Best Positioned, Qualified, and Equipped to Own Specific Interoperability Use Cases

After discussing interoperability-focused use cases, roundtable participants shared their take on additional considerations regarding involvement and ownership. The following points were raised:

  • Health plans are much better equipped to do population health management.
  • Providers are much better equipped to deal with care requirements and patients in real-time.
  • Everybody is investing in systems that are enormously expensive.
  • Providers are spending a lot of money on tools that if they had better collaborative relationships with payers, they wouldn’t have to invest in.

Payers and providers each need to ask: What does practical interoperability mean for our business and how do we design our businesses?

Listen here for more from roundtable participants on interoperability-related use cases

Informing Care Decisions & Providing Insights to Either Side of the Network

As an individual who works directly with payers and who has colleagues working directly with providers, Tim Capstick shared that Surescripts tends to focus on informing care decisions, providing insights across the network to both sides of the network, and enhancing the prescribing process for providers.

Tim shared that on the payer side there is a lot of concern and issue around the consistency in which providers are utilizing enhanced prescribing services, what providers are getting out of prescription services enhanced by interoperability and the overall return on investment? And on the provider side: what is the quality of this information that’s being presented? Is data consistently being presented and can the data be trusted?

Listen here for more from Surescripts Tim Capstick on informing care decisions and increasing the adoption of interoperability use cases.

Additional Interoperability-related Topics of Discussion – Coming in Part 2

The first Focus Area Roundtable on Interoperability facilitated by Surescripts covered a lot of areas of interest to participants – way more than can be reasonably shared in a single post. In the second part of this two-part recap, information on the following will be shared:

  • Trust, quality, and scarcity as a mechanism for increasing adoption of interoperability use cases
  • The importance of balancing the amount of information payers share with providers
  • Interoperability’s increasing importance and impact on value-based arrangements
  • The importance of workflow
  • An interesting comment about charging for access to healthcare data and how another participant responded

Come Learn More & Share Your Insight

Our second Focus Area Roundtable on Interoperability takes place on Tuesday, September 8th at 10:00 AM PT / 2:00 PM ET and will build upon the topics shared in the first roundtable. In addition, our Focus Area Partner Surescripts will share information on and respond to participant challenges, issues, and opportunities regarding interoperability collected in advance of the roundtable.  Leaders of health plans, health systems, and provider organizations can request an invite here.

Special thanks to Ashley Clark and Tim Capstick of our sponsor Surescripts for sharing their unique insight in this roundtable. For information on any of the topics presented in this post, contact Tim Capstick or Ashley Clark.

To receive additional information on interoperability and other healthcare leader priorities on the 2021 HCEG Top 10+ list, subscribe to our newsletter and follow us on Twitter and LinkedIn.

Payer-Provider Collaboration Critical to Meeting Price Transparency Mandates

By | Events, Focus Area Roundtable, HCEG Content | No Comments
  • Ignoring price transparency mandates will not make them go away

  • Will the No Surprises Act be the dagger in the heart of fee-for-service payments?

  • What changes to the No Surprises Act may be coming? And when?

  • Will Advanced EOB’s force payers and providers to collaborate more?

  • How might price transparency impact the workflow of health plans and providers?

  • Will price transparency regulations help patient engagement? Or create a customer service nightmare?

Our second Focus Area Roundtable on Price Transparency – facilitated by HealthSparq – took place on Wednesday, June 16th and members of the HCEG Network and industry thought leaders including Denny Brennan, Executive Director and Chief Executive Officer of HCEG partner Massachusetts Health Data Consortium (MHDC), raised and explored these and other questions.

Ferris Taylor kicked off the roundtable by asking Matt Parker, Vice-President of Products at HealthSparq, to frame the conversation by sharing a highlight of the keynote presentation “Path to Transparency – Increasing Access, Lowering Costs, and Driving Value that Matt presented along with two other healthcare leaders at the World Health Care Congress Virtual 2021 conference.

Price Transparency – Part of the Foundation for Patient Engagement

Matt Parker related that the Transparency in Coverage Mandate and No Surprises Act presents unique challenges for health plan payers and providers that can only be addressed via increased collaboration. Matt shared that price transparency is just a tool, a component to facilitate payer and provider interaction with their members and patients – not an end in itself but rather something for helping members, patients and providers better understand available provider networks, find care when they need it, engage with the system, and understand what costs are going to be – from both the member, patient, and provider perspective.

Matt suggested this price transparency foundation is the floor on which health plans and providers can build more holistic engagement with their members and patients.

RELATED: Recap of 1st Focus Area Roundtable on Price Transparencyhealthcare transparency in coverage. No surprises act. healthsparq price transparency

Building Upon the Floor Established by Price Transparency Mandates

To build upon the idea of compliance with transparency mandates as the floor, a health plan participant asked: How do we separate the basic needs of meeting the mandate from the next phase once pricing data is out there? And once basic needs are met, how can we then use that accomplishment to do things to support our members to engage with our providers more effectively? How can we help members with their provider relationship?

These few questions and others raised by participants affiliated with both health plans and provider organizations shaped the discussion and interaction throughout the roundtable.

Primary Topics Discussed by Roundtable Participantshealthcare data interoperability surescripts focus area roundtable HCEG

Our Focus Area Roundtables are informal discussions where all participants can contribute insight and raise questions. This post presents a number – but not all – of the contributions made by roundtable participants. Additional content will be shared in future posts, our social channels, and in future roundtables. To receive additional information on this and other Focus Area Roundtables, join our newsletter, follow @hcexecgroup on Twitter, connect with us on LinkedIn, and consider participating in upcoming roundtables.

RELATED: Join our Interoperability roundtable on July 20, 2021 at 10:00 AM PT / 1:00 PM ET

Who’s on First? Low Levels of Initial Compliance Due to Confusion?

One participant referenced a recent study published by JAMA that noted low compliance with the price transparency mandate by hospitals. In response, another participant noted that at his health plan, there was confusion about what is required and who is responsible for compliance with current price transparency mandates.  He noted that some staff were not aware of the upcoming January 2022 price transparency deadline for health plans, or thought it was provider-related, not health plan-related.

To be clear, while there are price transparency mandates for both providers and health plans, the JAMA study referenced the hospital-related mandate effective earlier this year on January 1st. Effective dates for price transparency-related mandates for health plans and the specific capabilities required are noted in the following table:

Transparency in Coverage Mandate – Health Plan/Payer

January 2022 Public access to pricing data through machine-readable files
January 2023 Personalized, out-of-pocket estimates via online, self-service tools
January 2023 Pricing data available for 500 services
January 2023 Pricing data available for all covered services via online tools or print delivery

No Surprises Act – Health Plan/Payer

Cost-sharing price comparison by phone or internet for specific service/item
Advance EOB w/ provider and contracted rate for in-network services. Out-of-pocket cost estimate for Out-of-Network services at least 3 days in advance
Provider directories updated & verified every 90 days w/ info updated within 2 business days of receipt. Health plan process for organizations not responsive to verification attempts.
RELATED: Diving into the Details: What You Need to Know About the Machine-Readable Files Mandate

Ideal Outcomes of Payer-Provider Compliance with Price Transparency Mandates

From a health plan perspective, compliance with price transparency mandates should help providers deliver care more effectively – as viewed by the patient. From the provider’s standpoint, a tighter integration with their health plans should enable providers to answer pricing questions from their patients.

If Mandates are Ignored, Will They Go Away – Or At Least Be Delayed?

Transparency in Coverage Mandate and No Surprises Act

MHDC’s Denny Brennan shared how some provider and payer organizations are viewing the mandates:

‘Perhaps there’s a bit of willful denial about sharing data partly driven by the fact that pricing information has long been held on the provider side in chargemasters, which are notoriously poorly maintained files with respect to what the patient’s actual exposure will be. Providers and plans are still looking at pricing data as part of their proprietary contracting process and may be essentially ignoring the mandate.’

Denny also offered that the idea of sharing pricing data hasn’t settled in across the industry because health plans are waiting for providers to take the lead and many providers are thinking: “We don’t know how to do that, we don’t know if we want to do that, and if we pretend it’s not happening, it may go away – especially because so many things have been pulled back with COVID-19.”

RELATED: Meeting Transparency Mandates: Put Your Employer Groups at Ease

Delays to No Surprises Act – Likely Clarified by August 2021

Ferris asked HealthSparq’s Matt Parker if he anticipated that the payer-side legislation might get delayed. Matt stated that while the Transparency in Coverage rules are finalized in theory, will take place over the next few years as defined, and will likely not be changed, there are not any sufficiently defined rules pertaining to transparency-related parts of the No Surprises Act – including the Advanced EOB requirements.  Matt also shared that updates to the No Surprises Act are likely to be released next month in July.

Listen here for more on potential delays to the No Surprises Act.

Other Mandates Taking Precedence over Transparency?

Participants noted that other regulations, mandates, and rules are taking precedence over – or at least complicating compliance with – the Transparency in Coverage Mandate and No Surprises Act including:

An Old Cliché Rings True: Garbage In – Garbage Out

One participant with decades of experience serving health plans noted that 80-90% of medical bills have errors of some type and this means that price transparency and data sharing mandates are starting from a system that is already error-laden. Accuracy needed to automate information interchange does not always exist and we have to clean up our act before we put it on stage.

She echoed questions posed by her clients:

  • Where am I going to pull this data from?
  • How am I going to get this out of my systems into data files?
  • Who are knowledgeable partners that can help with the generation and hosting of machine-readable files?
RELATED: Understanding the Transparency in Coverage Mandate

Health Plans as Definitive Sources of Health Information

On the topic of who’s best positioned to serve the information needs of members and patients, Denny shared that:

“What we’re telling our members is, and this is a tough message for the provider community, is that the route by which patients/members/consumers will be getting their health data is through their health plan. And the regular interchange and exchange of data between health plans and providers is great for providers who need to manage care. But providers are not envisioned in the rules as being the definitive source of patients/member/consumer health information – that’s going to be coming through their health plan.”

Incomplete and Insufficiently Specified Rules Hamper Meaningful Transparency

Healthcare data includes administrative, clinical, and financial data held by both providers and health plans and subject to HIPAA and other federal and state regulations. Denny shared his take on challenges health plans and providers are encountering due to insufficiently detailed regulations and unresolved elements of payer-provider-consumer interoperability for the purposes of value-based care.

Listen here for more on considerations regarding the current state of interoperability rules.

Advanced EOB’s – Forcing Payer-Provider Collaboration & Impacting Workflow Providers?

Providers need to be able to sufficiently integrate with health plans to get a fairly accurate estimate of the cost of specific procedures. Matt shared his take on the Advanced Explanation of Benefits (EOB) portion of the No Surprises Act and suggests it will force payers and providers to create a technology solution in their workflow.

Listen here for more on the impact of Advanced EOB’s.

RELATED: Advance EOB, Patient/Consumer Protections, and Reporting

No Surprises Act – The Dagger in the Heart of Fee-For-Service?Price Transparency Mandate Kills Fee-for-Service Payment. Value-based payment models

MHDC’s Denny Brennan shared his take on how the movement to more transparency and interoperability mandates may speed the movement to value-based payment arrangements.

“One of the things that I infer from these discussions is that the No Surprises Act is almost a forcing function. As I’ve said to members of our group, if there was ever a dagger, that could be driven into the heart of fee-for-service medicine, it’s the No Surprises Bill. Because in order to prop this thing up and to burden the physician with telling the patient at the point of care that: “Well we want to get you an MRI but if we get it down the street instead of in our own network you’ll save more money.” And physicians hate that. They don’t want to have those conversations. It’s hard enough to get physicians to talk about social determinants of health.

Listen here for more on the potential impact on fee-for-service payment models.

Impact of Increased Transparency on Customer Service

In response to participants’ discussion about transparency mandates forcing greater adoption of value-based care models, Ferris asked whether there might be a consumer backlash based on missing or inaccurate pricing information and how it might be solved. One participant predicted a customer service nightmare for health plans and providers, and another stated that it’s a problem that is going to be solved by a crowd – not by individual organizations.

Listen here for more on the potential impact of mandate compliance on customer service.

RELATED: Price Transparency Resources for Health Plans

Connect with Others Facing Similar Challenges

Special thanks to Matt Parker and HealthSparq for their role as our Focus Area Partner for Price Transparency. For more information on the meeting and exceeding price transparency mandates and to learn more about topics presented in this post, check out HealthSparq’s website and contact HealthSparq here.

If you’re a leader of a health plan, health system, or hospital/provider organization, consider joining future Focus Area Roundtables on Price Transparency, Interoperability, NextGen/Value Payment Models, and Healthcare Policy & ACA. We have other Focus Areas of the 2021 HCEG Top 10+ under development.Healthcare Executive Group Focus Area Partners HealthSparq Softheon Surescripts Zelis